Cases & Commentaries

Failure to enter documentation of a DNR order causes a severely ill elderly man to be resuscitated against his wishes. Shortly thereafter, the patient's wife confirms his wishes, and within minutes, the patient dies.

Cases & Commentaries

An elderly, non–English-speaking man with diabetes was admitted to the hospital twice in 8 days due to hypoglycemia. At discharge, the patient was instructed not to take any antidiabetic medications. In between hospitalizations, he saw his primary care physician, who restarted an antidiabetic medication.

Cases & Commentaries

A 91-year-old woman is found lethargic and incontinent, with slurred speech. Review of her medications reveals numerous duplicates, including some considered potentially inappropriate for use in elderly patients.

Journal Article > Study

This study of more than 50 ambulatory practices discovered that about 7 in 1000 outpatients receive a medication that counters black box warnings. While these events were associated with very few instances of patient harm, investigators noted that older patients with multiple medical problems and taking more medications appeared to be at greater risk for being prescribed these medications. Data collection occurred through review of electronic health records that offered limited clinical decision support or alerts to providers. The authors suggest that improvements in decision support may minimize the potential for such black box warning violations. This study reports an overall lower rate of prescribing violations compared to past published work.

Journal Article > Study

The authors reviewed discharge medication records for elderly patients to assess documentation problems leading to medication errors. They conclude that communication at discharge needs to be improved, along with system changes to support the adoption of new practices.

This AHRQ–funded study discovered that the use of alerts within an electronic medical record system can reduce the number of unsafe medications prescribed in elderly outpatients. Investigators evaluated the impact of a clinical decision support system (CDSS) at the point of computerized provider order entry (CPOE), targeting two classes of contraindicated medications (long-acting benzodiazepines and tertiary amine tricyclic antidepressants). The authors discuss the rapid, significant, and persistent reductions in medication prescribing of these high-risk medications, suggesting the effectiveness of an alert system to curtail inappropriate prescribing. This study is a first to evaluate a computerized alert system in a large population-based primary care setting, although a past systematic review evaluated the effects of CDSS on practitioner performance and patient outcomes.

Electronic medication administration records (eMARs) are one technology solution being applied to reduce the potential for medication errors. This AHRQ-funded study provides detailed descriptions and learnings from a quality improvement effort to implement eMARs in five nursing home facilities.

Newspaper/Magazine Article

Detailing a case in which latent failures led to patient harm, this article encourages health care providers investigating adverse events to consider how both active and latent failures may line up to cause errors.

Journal Article > Study

An extensive body of literature documents the unintended consequences of information technology in the inpatient setting. This qualitative study identifies many similar unintended consequences after introduction of electronic health records into Australian nursing homes.

In this study, 8 out of 10 older home care patients in Finland had discrepancies between the medications they reported taking and those listed in their electronic medical record. Approximately 40% of these discrepancies were considered clinically important.